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PURPOSE- Emergency surgery is a traditional treatment option for patients with malignant left sided colonic obstruction which involves defunctioning stoma with or without primary anastomosis. Colonic stenting as a bridge to elective surgery has been proposed as an alternative to emergency surgery. Recent randomized controlled trials have assessed the efficacy of colonic stents as a bridge to elective surgery compared to emergency surgery in the management of malignant colonic obstruction. We performed a meta-analysis of the RCT's to compare the efficacy and safety of stent compared to emergency surgery in left sided colonic obstruction.
METHODS-
Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (through 11/12).All the studies assessing the efficacy of colonic stent as a bridge to elective surgery compared to emergency surgery are included. Standard forms were used to extract data by two independent reviewers. Data regarding the following outcomes were extracted-number of primary anastomosis, overall stoma rate, success rate, complication rate, infection rate, number of patients with anastomosis leakage and mortality rate.
RESULTS- Seven studies met the inclusion criteria (n=341). Mean age ranged from 62 -74 yrs. Studies were reported from China, UK, Spain, Singapore, France, Netherlands. Colon stents used were Wallflex of 25mm and Wallstent of 22mm diameter. All patients had malignant left sided colon obstruction. Success rate (defined as clinical relief of obstruction) was higher in surgery group compared to stent group (OR 18.8 95%CI 6.15-57.89, p<0.0001). Primary anastomosis rate was significantly higher in stent group compared to emergency surgery group (OR 2.8 95% CI 1.6-4.7, p=0.0001). Overall stoma rate was lower in stent group (OR 0.39 95% CI 0.19 -0.8, p=0.01). Overall complication rate was significantly lower in stent group compared to surgery group (OR 0.30 95% CI 0.12-0.72, p=0.007). There was no significant decrease in infection rate in stent group compared to surgery group (OR 0.54 95% 0.24 - 1.19, p =0.12). There was no significant difference in anastomosis leak between two groups (OR 0.73 95% CI- 0.18-2.9, p=0.67). No significant difference in mortality rate observed between two groups (OR 0.95 95% CI-0.41-2.18, p=0.91).
CONCLUSION- Success rate (relief of obstruction) was higher in emergency surgery group compared to stent group. Primary anastomosis rate, overall stoma rate and complication rate was lower in stent group compared to surgery group. There was no significant difference in infection rate, anastomosis leak and mortality rate in between the two groups.